Provider Demographics
NPI:1518962612
Name:GOGGIN, MARK T (M D)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:T
Last Name:GOGGIN
Suffix:
Gender:M
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1515 MAPLE DR
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:OH
Mailing Address - Zip Code:43725-1162
Mailing Address - Country:US
Mailing Address - Phone:740-439-3515
Mailing Address - Fax:740-432-6427
Practice Address - Street 1:1515 MAPLE DR
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:OH
Practice Address - Zip Code:43725-1162
Practice Address - Country:US
Practice Address - Phone:740-439-3515
Practice Address - Fax:740-432-6427
Is Sole Proprietor?:No
Enumeration Date:2005-06-15
Last Update Date:2007-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35069467207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0248762Medicaid
OHG66667Medicare UPIN
OH0844711Medicare ID - Type Unspecified